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Betty Kelman RN-EC MEd C Neph (C)University Health Network: Toronto General Hospital
Toronto Ontario Canada
Objectives Peritoneal Dialysis Nursing
By the end of this session, the learner will be able to
•
Differentiate a novice from an expert based on Benner’s classification of nurses
•
Describe survival skills for a novice •
Discuss the development of expert skills based on knowledge & experiential learning
http://www.ajc.com/multimedia/dynamic/01139/2012-poster-min_1139293g.jpg
http://www.emergiblog.com/wp-content/uploads/2007/08/baby_nurse_72006.jpg
The success of a PD programme is dependent upon specialized nurses
with
appropriate skills
in assessing and training patients for PD,
monitoring of treatment and with sufficient resources to provide
continued care in the community.
http://www.renal.org/Clinical/GuidelinesSection/PeritonealDialysis.aspx
Dr Graham Woodrow & Prof Simon DaviesPeritoneal Dialysis in CKD
The PD nurse is thus the key individualin the PD unit, & most activities involve& revolve around the nursing staff.
It is therefore not surprising that mostnephrologists pay considerable attention to the selectionof PD nurses, particularly in long-term PD programs such
as continuous ambulatory peritoneal dialysis (CAPD). The appointment of a PD nurse depends
on finding an individual with the right attributes,
broad general experience,& appropriate training.
Tan PC, Morad Z. Training of peritoneal dialysis nurses. Perit Dialy Int Dec 23 (Suppl 2) , S206-209
Five Stages of Nurse Developmentfrom Patricia Benner’s
Model of Novice to Expert (2001)Educator’s Resource:
Integration of Best Practice Guidelines
Registered Nurses’ Association of Ontario (2005)
http://www.bing.com/images/search?q=novice+to+expert&view=detail&id=1FFD539EC149B464BB65C3785E6B6ECFEAB23430&first=0&FORM=IDFRIR
Novice
•
No experience for situations expected to perform
•
Rigid adherence to rules or plans•
Little situational perception
•
Unable to use discretionary judgement•
Focuses on pieces rather than the whole
http://scrubsmag.com/10-rules-for-nursing-students
The person who is afraid to ask questions is afraid of learning!
Old proverb
www.hsl.virginia.edu/.../1951nursementor.jpg Morad et al PDin MalaysiaPDI, Vol 25 # 5, 2005
Advanced Beginner
•
Guidelines for action based on attributes or aspects•
Situational perception still limited
•
Demonstrate marginally acceptable performance•
Notices change but cannot cope with it
•
All attributes and aspects treated separately & given equal importance
•
Unable to see entirety of new situation
http://nursinglink.monster.com/nfs/nursinglink/attachment_images/0006/3914/1084_stressed_out_nurse_running.jpg_max160.png?1219130712
Competent
•
Aware of all the relevant aspects of a situation
•
Sees actions at least partly in terms of long-term goals
•
Conscious of deliberate planning•
Can set priorities
•
Critical thinking skills are developing
http://www.jaxhealth.com/img/stock/NurseMentor_300px.jpg
Proficient
•
Sees situations holistically rather than in terms of aspects
•
Sees what is most important in a situation •
Perceives deviations from the normal pattern
•
Decision making less laboured•
Uses guidelines and maxims for guidance
http://www.bing.com/images/search?q=expert+nurse&view=detail&id=853152ABA7F917E1CB7CD6EBFF6E7E84A2B9473A&first=61&FORM=IDFRIR
Expert
•
No longer relies on rules, guidelines or maxims
•
Intuitive grasp on situations based on deep tacit understanding
•
Analytic approaches used only in novel situations or when problems occur
•
Vision of what is possible
NoviceBuilding on existing foundations
http://www.bing.com/images/search?q=novice+to+expert&view=detail&id=1FFD539EC149B464BB65C3785E6B6ECFEAB23430&first=0&FORM=IDFRIR
Experiential Learning
•
Making meaning from direct experience •
Active engagement in reflecting on experience
•
Decision making & problem solving
http://cdn.fantasypros.com/wp-content/uploads/Consensus.jpg
Experiential Learning
•
Eureka moments–
“light bulb moments”
•
Building knowledge•
Developing skills
•
Intuitive approaches
www.youthchg.com
Peritoneal dialysis (PD) center is not possibleto operate if there is no availability of
dedicated PD nurse. Generally, the nurse hasto play many roles, including educator,coordinator,and sometimes leader.
As professionals, the PD nurses need to
have both theoretical & practical skills.
Thaiyuenwong J, Mahatanan N, Jiravaranun S, Boonyakarn A, Rodpai S,Eiam-Ong S, Tungsanga K, Dhanakijcharoen P, Kanjanabuch T. Nationwide peritoneal dialysis nurse training in Thailand: 3 year experience J Med Assoc Thai. 2011 Sep;94 Suppl 4:S162-6
Foundations
The learner has an understanding of•
Chronic kidney disease (stage V)
•
Pharmacology related to patient population
•
Impact of chronic illness
thekidneycenter.org
Foundations
The learner is •
Open to new learning
•
Free to acknowledge learning needs•
Appreciate the learning curve
•
Willing to embrace new experiences and build on foundations
And above all …
http://www.bing.com/images/search?q=Nursing+Clip+Art&view=detail&id=FF0BBF57444480B793F9CBE4D8A3121F5C343035&first=0&qpvt=Nursing+Clip+Art&FORM=IDFRIR
Peritoneal Dialysis: Strategies to Maintain Competency for Acute
& Extended Care Nurses (J.Farina)
•
Basic principles of peritoneal dialysis
•
PD assessment and documentation•
Aseptic technique
•
Trouble shooting common problems
Nephrology Nursing Journal 35 (3) May-June 2008, p 271-275
Peritoneal Dialysis: Strategies to Maintain Competency for Acute &
Extended Care Nurses (J.Farina)
Procedures•
Peritoneal catheter management
•
CAPD•
CCPD
•
Collecting samples
Nephrology Nursing Journal 35 (3) May-June 2008, p 271-275
PD procedures &the potential for patient success
might be more robust if biomedical approachesto PD are more fluid. Fluidity does not mean
that PD processes and procedures mutate into afree-for-all procedure where patients and nurses
can do as they please.
Safe practice requires some boundaries. .
•http://1.bp.blogspot.com/_BEzjzFrkL6o/TECgDzezhTI/AAAAAAAAAEw/rT2AvTo9e_M/s1600/env+fluidity+the+cubes+maze1.png
McCarthy, A., Cook, PS., Fairweather,C., Shahan, R., Martin-McDonald, K. (2009) Compliance in peritoneal dialysis: A qualitative studyOf renal nurses. Inter Jour of Nursing Practice 15, p 219-226.
Survival Knowledge
•
Principles–
Fluid removal by osmosis
–
Understanding use of solutions •
Patient assessment
•
Aseptic technique •
Therapeutic relationships
www.advancedrenaleducation.com/Portals/0/JPEG...
Survival Skills
•
Procedures–
Safe demonstration of technical aspects of dialysis
•
Problem-solving –
Demonstrates basic approach to identification and management of problems
As time goes by
•
Able to do more than perform–
Interprets findings of PET
–
Interprets findings of adequacy studies–
Discusses changes in prescription based on assessment of patient and findings
–
Applies to the individual
http://mymed.jp/disease_img.php?path=y6r/Image/%E3%82%B9%E3%83%A9%E3%82%A4%E3%83%897(1).JPG&mw=270
As time goes by
Follows guidelines for management BUT•
Incorporates experiential learning–
Thinks beyond the guidelines
–
Reviews options–
Adapts for the individual
As time goes by
Follows guidelines for management BUT•
Questions practice
•
Analyzes recommendations•
Critiques literature
•
Acknowledges own learning needs for higher levels
We developed this program for nurses who train patients in peritoneal dialysis.
Because nurses have not been professionally trained as teachers, they
inadvertently often begin teaching without considering what they specifically want their patients to learn or how they are
actually going to teach them..
Judith Bernadini BSNMary Bird NurseUniversity of Pittsburgh Center of Instructional Development & Distance Education (CIDDE)
Nurses tend to teach as they were taught, following the model of “seeing
one, doing one, teaching one.”
We propose an alternative model of patient
training that follows principles of learning and focuses on the nurse’s role
as teacher.
Judith Bernadini BSNMary Bird NurseUniversity of Pittsburgh Center of Instructional Development &Distance Education (CIDDE)
Holistic Learning (Virginia Griffin)
Emotional•
Learning blocks –
Frustration
–
Fear–
Guilt
–
Hurt–
Confusion
–
Anger
Lifelong Learning
Nurses as•
Teachers
•
Facilitators•
Counselors
•
Coaches•
Fellow Travelers
•
Learners
http://www.bing.com/images/search?q=Nursing+Clip+Art&view=detail&id=5C026348DF1104B6489C8DEDD1822AD87FF65F8E&first=91&FORM=IDFRIR
Nurse as teacher
Compliance•
Less experienced(< 2 years in PD)–
“nurse knows best”
–
patient recognition of the nurse’s authority is fundamental to own professional performance
“They do it without argument & they appreciate the effort that as nurses we put in.”
McCarthy, A., Cook, PS., Fairweather,C., Shahan, R., Martin-McDonald, K. (2009) Compliance in peritoneal dialysis: A qualitative studyOf renal nurses. Inter Jour of Nursing Practice 15, p 219-226.
Nurse as teacher
Compliance•
More experienced (> 2 years in PD)–
Sensitized to rigid demands of PD
“But it’s not necessarily what the patient wants. . . . You know, this is not an easy thing for people
to incorporate into their lives … it’s very difficult,very hard.”
McCarthy, A., Cook, PS., Fairweather,C., Shahan, R., Martin-McDonald, K. (2009) Compliance in peritoneal dialysis: A qualitative studyOf renal nurses. Inter Jour of Nursing Practice 15, p 219-226.
Experiential LearningClinical Vignettes
http://www.bing.com/images/search?q=novice+to+expert&view=detail&id=1FFD539EC149B464BB65C3785E6B6ECFEAB23430&first=0&FORM=IDFRIR
The road to wisdom?
Well, it’s plain and simple to express: Err and err and err again
but less and less and less.
Piet Hein
www.wendingwayfare.com
Foundations
•
Assessment–
Fluid balance
–
Assessment (weight/B/P/physical findings)–
Application of learned guidelines
Strength of Solution (%)
Osmolarity (mOsm/L)
Effect (60 min dwell time)
0.5 296 Less return1.5 346 50 –
150 mL2.5 396 100 –
300 mL
4.25 485 300 –
400 mL
Novice: CAPD bag selection for
target weight
Weight Bag SelectionIf more than 0.5 kg below TW
0.5%
If +/-
0.5 kg 1.5%If 0.6 to 1 kg 2.5%If greater than 1 kg 4.25% (or Icodextrin)
http://maximummarketer.com/wp-content/uploads/contributing-authors-rules-and-regulations/maximummarketer-rules-and-regulations.jpg
Nurses interpret order
•
Patient weighs 70 kg –
Remember, target weight is 72 kg
•
B/P is 180/100•
Short of breath
•
Peripheral edema
By scale, use 0.5%
Doctor’s OrdersCAPD 2 L QID
TW = 72 kg (full)(taken from clinic 2 months ago)
Novice Nurse
•
Assesses patient•
Studies guidelines
•
Hangs 0.5%•
Later places call to MD that patient has increasing shortness of breath
http://4.bp.blogspot.com/_bhjF5J7Nwck/TVHirMiqkXI/AAAAAAAAAC4/_ej_jVcLJVo/s1600/nursing+student.jpg
Proficient Nurse
•
Assesses patient–
Determines discrepancy between patient’s condition and bag selection guide
•
Places call to have target weight reassessed
http://janekgwizdala.com/home/wp-content/uploads/rules.jpg
Expert Nurse
•
Assesses patient•
Advises MD about documentation of weight and need to re-assess
•
Suggests alternate prescription for weight removal
http://alexwhalley.com/wp-content/uploads/2010/03/think_outside_the_box_brain_cp.jpg
Assessing response
Strength Volume infused (mL)
Volume drained (mL)
Balance(mL)
Cumulative u/f (mL)
4.25% 2000
2.5% 2000 2700 -700 -700
4.25% 2000 2300 -300 -1000
2.5% 2000 2650 -650 -1650
4.25% 2000 2350 -350 -2000
Problem Solving
•
Patient achieves new target weight•
Changed to 1.5% to maintain weight
www.renalresource.com
Foundations
Problem solvingApproach
–
Defining issue–
Using rules and regulations to manage
–
Lack of context for situation
Assessing response
Time Strength % Volume infused (mL)
Volume drained (mL)
Balance(mL)
0600 1.5 2000
1200 1.5 2000 2200 -200
1800 1.5 2000 2100 -100
2200 1.5 2000 2250 -2500600 1.5 2000 1600 +400
Novice Nurse
•
Notes decreased drainage•
Repositions patient
•
Calls MD for advice•
Remembers common cause of slow drain
http://4.bp.blogspot.com/_bhjF5J7Nwck/TVHirMiqkXI/AAAAAAAAAC4/_ej_jVcLJVo/s1600/nursing+student.jpg
http://30.media.tumblr.com/tumblr_lroy3xn2gU1r3pg0uo1_400.jpg
MENTOR“Don’t ever
forget that the reason people don’t drain is most often related to
constipation!!”
Expert Nurse
•
Reviews records•
Considers reason for decreased drain volume–
Absorption overnight
–
Incomplete filling•
Assesses abdomen•
Checks a.m. weight, –
compares with p.m.
–
Catheter dysfunction•
Considers irrigation
http://alexwhalley.com/wp-content/uploads/2010/03/think_outside_the_box_brain_cp.jpg
Foundations
•
Problem solving–
Catheter management
–
Dialysis issues–
Assess problem•
Determine if correct approach
•
Trial and error•
More experience = more options
Clinical Context
•
Patient admitted –
CCPD, but not dialyzing at home
–
CCPD initiated•
Low drain alarms
•
Reposition patient•
Continuing low drain alarms
Novice Nurse
•
Looks at manual•
Determines ongoing alarms
•
Patient complains not able to sleep•
Turns machine off
http://4.bp.blogspot.com/_bhjF5J7Nwck/TVHirMiqkXI/AAAAAAAAAC4/_ej_jVcLJVo/s1600/nursing+student.jpg
Expert Nurse
•
Bypasses one cycle, still poor flows•
Disconnects patient
•
Assesses catheter flow–
Notes resistance with irrigation
•
After successful irrigation–
Manual exchanges x2
http://alexwhalley.com/wp-content/uploads/2010/03/think_outside_the_box_brain_cp.jpg
Fibrin affecting patency
Flush–
10 mL volume
–
Retry with 30 mL volume•
In & out irrigation
•
Fibrin plug removed•
Flow re-established
www.nature.com/.../v78/n9/images/ki2010236f1.jpg
Novice
“We saved the bag for you.
It looked cloudy…
oh, and it was brown
coloured.”
http://www.emergiblog.com/wp-content/uploads/2007/08/baby_nurse_72006.jpg
Expert Response
Inner voice
Outer ActionNot to be repeated
Clinician & Mentor
1.bp.blogspot.com/.../CALM-CAT-FINAL-amst.jpgvintageholidaycrafts.com/wp-content/uploads/2..
Vignette: the unexpected
63 year old female
• Admitted for management of calciphylaxis• Developed pleural effusion• Pleural tap done•
Patient drained for procedure
•
CAPD resumed post procedure
Approach to patient
• Query perforation of blood vessel• Physical exam
• Vital signs stable• Abdomen
• No tenderness• No distension• No rebound
• Assessment of peritoneal fluid• In & out flushes
As time goes by
Dreyfus/Benner Steinaker & Bell RCOG (UK)
Novice Exposure ObservesAdvanced Beginner
Participation Assists
Competent Identification Direct Supervision
Proficient Internalization Indirect Supervision
Expert Dissemination Independent
http://www.umdnj.edu/idsweb/idst5340/models_skills_acqusition.htm
As time goes by
Centre Effect
•
Nationwide survey (Netherlands, Huisman, 2002)–
Clear cut increased risk of PD failure in centres with less than 20 patients
•
Hong Kong–
11 publicly funded centres
–
Range of patients 79-417–
Better outcomes given high percentages on PD
Li & Chow,How to have a successful PD program PDI Vol 23, S 2, 2003
As time goes by
Nurses’ experience & peritonitis•
Higher experience–
associated with progressively increased risk
•
Striking negative association–
between time in practice & peritonitis
Chow et al (2007) Influence of PD Training Nurses’ Experience on Peritonitis Rates, CJASN, 2:647-652 ,
http://www.google.ca/imgres?q=passage+of+time&um
Chow K M et al. CJASN 2007;2:647-652
©2007 by American Society of Nephrology
Kaplan-Meier survival curves demonstrating the probability of Gram-positive peritonitis-free survival among patients who were trained by nurses with various levels of experience.
.
Through many years of experience, the PD staff have learned that initial successes can slide unless vigilance is applied to constantly monitor, assess, & act as needed.
White, S., Vinet, A. (2009) Partnering with patients to improve peritonitis rates. Advances in Peritoneal Dialysis, Vol. 25, 2009
White, S., Vinet, A. (2009) Partnering with patients to improve peritonitis rates. Advances in Peritoneal Dialysis, Vol. 25, 2009
.
The team will continue to ground their interventions using soundprinciples of chronic disease
management, emphasizing respectful partnerships and recognizing the key
role that patients must play in maintaining their health.